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Distal RCA...

Left Main...

Occluded Left...

Techniques Used

Multiple complex bifurcation techniques including modified crush, mini crush and culotte with use of anchoring balloons

SYNERGY Platform characteristics

The two connector design on the stent body, vessel conformability4 and large side-branch access3 allowed for multiple bifurcation techniques

Ability of stent overexpansion, when called for during post dilatation, to match the diameter of larger vessels, and permits complex LM intervention. (The SYNERGY 4.0 mm dedicated stent has a labeled overexpansion capability of up to 5.75 mm5)

Its deliverability, visibility and conformability4 allowed for full revascularisation of complex disease

SYNERGY Drug & polymer characteristics

Abluminal coating and synergistic drug release1 with polymer degradation* facilitates early healing6 from day one and thus allows for flexibility of DAPT duration7. Polymer is gone after completion of drug elution at 3 months. This is an important consideration when baseline morbidity is unknown as in this case where the patient presents with cardiogenic shock

Acute Procedure (Primary PCI to LAD/D2 bifurcation)

Flow re-established in LAD/D2 with a 2.5 mm compliant balloon but D2 dissected

A “crush” bifurcation strategy chosen for 2 reasons: vessel size disparity and maintaining flow in dissected diagonal by stenting it first with a 2.25 x 32 mm SYNERGY DES placed from mid LAD to D2 and optimised with a 2.5 mm NC EMERGE balloon

Crushed with 3.0 x 15 mm compliant balloon in LAD (modified crush technique – using a balloon rather than a stent)

Acute Procedure (Left main/circumflex bifurcation)

1st marginal circumflex (OM1) stented directly with a 2.5 x 24 mm SYNERGY DES back into left main/LCX os in a “mini crush” strategy, optimised with a 3.0 mm NC balloon and crushed with a 3.5 mm balloon in the LMS

LMS to LAD stented with a 4.0 x 28 mm SYNERGY DES and optimised with a 4.0 mm NC balloon. The LMS was proximally optimised with a 5.0 mm NC balloon ensuring both stent apposition and side branch access to the LCX, and demonstrating stent over-expansion characteristics